Clinical and epidemiological characteristics and individual experiences of illness in men with COVID-19: mixed method study

ABSTRACT BACKGROUND: Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, studies have shown that this disease has affected the male population on a significant scale in various parts of the world, making men one of the main risk groups. OBJECTIVE: To analyze the clinical and epidemiological characteristics and experiences of illness in men with COVID-19. DESIGN AND SETTING: A mixed sequential-explanatory study with cross-sectional and exploratory-descriptive approaches. METHOD: Data was collected from a small municipality located in the central-north region of the state of Bahia, Brazil. Primary quantitative data was extracted from compulsory notification forms from 598 men. Qualitative data from individual interviews of 30 men was analyzed by the Discourse of the Collective Subject method. RESULTS: The findings identified the characterization of reports of suspected and confirmed cases of COVID-19 in men, the organization of the healthcare system, and strategies for the control and combat of COVID-19 directed towards the men of the investigated municipality. They revealed the clinical characteristics based on the collective discourse of men with COVID-19. CONCLUSION: In men, the individual experience of disease explicitly explains the clinical markers of COVID-19 expressed by the self-reported syndromic approach. Additionally, this understanding also explains the behaviors observed in their search for health care, as well as the adoption of prevention and control measures and therapies recommended by health professionals.


INTRODUCTION
Coronavirus disease 2019 (COVID-19) has significantly affected the male population in various parts of the world. [1][2][3][4] In countries such as Brazil, the number of cases of the disease in men varies according to municipality. [5][6] In addition to being the most affected gender, men have the worst clinical outcomes. Among the population that progressed to a picture of severe acute respiratory syndrome (SARS) caused by COVID-19, until the epidemiological period from February 21st to 27th, 2021, 62,613 cases were registered, with 54.5% of these cases comprising men. The most affected age group from this population was between 60 and 69 years, with a total of 24,775 cases (21.6%). Regarding deaths caused by SARS due to COVID-19 in Brazil, during this period, 16,444 (54.3%) were men, with the most affected age group between 70 and 79 years old, with a total of 7,717 (25.5%). 7 Several reasons have been suggested in the literature for the difference between sexes in the presentation of COVID-19, which indicate that being male is a risk factor for the new disease. Among these reasons, the influence of hegemonic patterns of masculinities was highlighted. This legitimizes the dominant position of men in society, which can contribute to the neglect of health care, and the disregard and disrespect for measures to prevent and control the transmission of SARS-CoV-2. 8,9 There are also factors related to habits such as smoking, abusive consumption of alcohol and other drugs, sedentary lifestyle, and clinical conditions, such as the presence of chronic diseases which occur more often in men. Moreover, new causes have been recognized with the arrival of the pandemic, namely hormonal factors related to testosterone 10 and generators of repercussions on sexual and reproductive health, 11 genetic factors of chromosomal origin, 12 and immunological factors 1,3 .
Another relevant aspect to be considered that has also been occurring in the context of the pandemic, is that a large proportion of the male population delays searching for healthcare services. 7,9 This resistance to seeking healthcare is necessary for the early detection of COVID-19 infections and leads to increased underreporting and/or late compulsory notification. It also leads to the progression of infections into more severe and complex clinical situations. Moreover, one cannot lose sight of the aspects related to weaknesses in healthcare services and networks, limited healthcare human resources 13 and the presence of barriers to access and sensitize the male population for health promotion and prevention of diseases and avoidance of injuries. 14,15 When considering the presence of a gap in scientific knowledge in the difference in disease presentation based on sex and gender, and given the clinical and epidemiological context of men with COVID-19, the combination of quantitative and qualitative approaches used in this study is justified. A joint study may contribute to a broader interpretation of the investigated problem, providing better evidence for best practice care for men with COVID-19.

OBJECTIVE
To analyze the clinical and epidemiological characteristics and experiences of illness in men with COVID-19.

Research design
A mixed methods study, with sequential-explanatory type from a transverse and analytical study, and an exploratory-descriptive research with a qualitative approach. In this study design, the quantitative approach was developed first and had the greatest weight; that is, it is the priority stage of the research. Next, a qualitative approach of secondary weight and complementary character was developed. Quantitative data were extracted from COVID-19 compulsory notification forms. Individual interviews were conducted at the qualitative stage. Thus, the data collected in the quantitative stage led and directed the data collection of the qualitative stage, 15 especially regarding the details of clinical characteristics and experiences of patients such as the recognition of signs and symptoms, perception of the disease, adherence to therapies and treatment, and apprehension of senses and meanings.

Data collection period
The study population consisted of suspected cases of infection with the COVID-19 in men, notified to the municipal epidemiological surveillance, from February to December 2020.

Selection criteria
Suspected cases of COVID-19 infection were individuals with an acute respiratory condition, characterized by at least two of the following signs and symptoms: fever (even if referred), chills, sore throat, headache, cough, runny nose, olfactory disorders, or taste disturbances.
The study excluded males who passed through the city, were suspected, or were assisted/notified during the data collection period.

Sample
The quantitative sample consisted of 598 men, notified as suspected cases of SARS-CoV-2 infection from February to December 2020. The qualitative sample consisted of 30 men with a confirmed diagnosis of COVID-19 presenting with symptoms.
The men included exclusively accessed the Municipal Center for Coping with COVID-19 and sought care. In addition, we sought participants who only accessed the service to ensure greater sample specificity, considering that it is a rural municipality, with habits, customs, and health behaviors that may have influenced the way they experienced the disease. The municipal health department, epidemiological surveillance sector, and participants agreed to access the data contained in the medical records.

Data collection
Data were collected in the municipality of Quixabeira, Bahia, Brazil, from October to December 2020. During this period, the municipality had 598 notified cases, diagnosed using reverse transcription polymerase chain reaction (RT-PCR) (311 cases) or rapid tests (87 cases).
At the end of that period, seven cases were still under monitoring, awaiting test results. Of these, 121 cases were positive: 77 (63.6%) were women and 44 (36.4%) were men. The municipality registered three cases of clinical admissions in a reference emergency care unit, one case of hospitalization requiring assistance in the intensive care unit, and no confirmed cases of death during the investigated period.
Data collection was conducted in two stages. The firstthe quantitative stage -was based on data from the Municipal  How does COVID-19 manifest clinically? This management was conducted using data surveys in the quantitative stage.

Data processing and analysis
For data collection, notification forms were accessed from the health surveillance department after prior authorization. Then, data from the forms were read, organized, and encoded in a spread- This method consists of pointing out, from each answer, the KEs, which are the CIs of the discursive content expressed by the interviewees. 16 The data described on the form of a Discourse-Synthesis, first person singular, represent the DCS of the men.
After the analysis of the quantitative and qualitative data, a combination of the data was conducted through the connection and integration of the results. Thus, additional information on the study objectives was identified.
Since this research was conducted in the context of the still-inprogress COVID-19 pandemic, ethical requirements in research were fulfilled, which involved biosafety to preserve the participants and researchers. The interviews were carried out with the researchers duly dressed in compliance with social distancing.
The application of the Free and Informed Consent Term was associated with the dispensing of alcohol gel and disposable tissues to access the pens made available by the researchers.

RESULTS
The first part of the results, derived from notifications, describes the clinical and epidemiological characteristics of men with COVID-19. The second part presents data from patient records, relating to clinical and epidemiological features and the control and combat strategies for COVID-19. Finally, the third source of data presents the clinical characteristics from the collective discourse of participants, retrieved from interview audio.

Characterization of reports of suspected COVID-19 cases in men
This study included 515 reports of suspected COVID-19 infections in men living in the municipality. As shown in Table 1, most notifications were made by health services in the state itself (98.6%), predominantly men aged 25-59 years (61.9%), mixed race (57.5%), and those who did not work in healthcare (98.6%) ( Table 1). Figure 1, there was an increase in the number of notifications from April to August 2020, when the peak in the number of notified cases occurred. From then on, there was an oscillation in the number of suspected cases registered, with an increase during April to August 2020. The increase in the number of confirmed cases followed what happened with the notifications (Figure 1).

As shown in
Data analysis showed that 20.6% of cases were notified eight days or more after the onset of symptoms, causing delays in the surveillance process and possibly in the medical care of these patients. As shown in Figure 2, there was a delay in notification among patients kept in home care or who died (Figure 2).
The results also showed that death occurred in older men (≥ 60 years). The men kept in home care, who were negative for COVID-19, had an average age of 19-24 years. Reports of young teens and adult men who had confirmed COVID-19 infections predominantly progressed to cure (Figure 3).
The secondary Qual stage of the study involved data from 30 interviews with participants in the first quantitative stage, which was explained in the form of discourse synthesis. Its respective CIs were framed, theoretically, from the fields/variables that make up

Discourse-synthesis: Clinical characteristics, from the collective discourse of men with COVID-19
The male collective discourse revealed that the clinical char-      The direction of COVID-19 prevention and epidemiological control strategies among the male population must consider the sociodemographic profile, such as race/color, social class, and occupation, and clinical profile related to signs and symptoms, complaints, complications and infection pattern. 26 It is necessary to direct more attention specifically to the adult male population, considering that this population is economically active and widely distributed, and, consequently, is more exposed to SARS-CoV-2.
Furthermore, according to Brazilian literature, this population has adhered less to preventive health care 27,28 . Even out of the context of high risk for viral transmission, male population was more prevalent in the findings identified in this study. Finally, with satisfactory effects of the use of these joint efforts, it is possible to reduce the economic impact on the national health system, ensuring greater sustainability of the system before a crisis context. In addition, this will guarantee increased survival and a reduction in male mortality by COVID-19 and secondary complications to the disease, reducing the burden of services and health professionals and will in turn ensure an early and safe return of non-essential daily activities and promotion of social welfare, with positive effects influencing the culture of health care.
As a limitation of the study, some of the cases had incomplete information documented in the medical records, and the clinical documentation of the patients was not homogeneous. However, this is a common limitation in analytical studies, considering that data generation is clinically oriented and not systematically oriented.

CONCLUSION
The clinical and epidemiological characteristics of men in the investigation of suspected and confirmed cases of COVID-19 were designed for adult men aged 25 to 29 years, mixed race/ color, and who did not work in health care. Compulsory notifications were carried out in the municipality of their residence, with an increase in the period from April to August 2020, representing a peak in notified cases. Fatality and maintenance of home treatment were higher among elderly men, and a progression to cure predominated among adolescent, young, and adult men.